Non–Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease

End-stage renal disease (ESRD) patients have a higher prevalence of diabetes mellitus, hypertension, congestive heart failure and advanced age, along with an increased incidence of non-valvular atrial fibrillation (AF), thereby increasing the risk for cerebrovascular accidents. Systemic anticoagulation is therefore recommended in patients with ESRD with AF to reduce the risk and complications from thromboembolism. Paradoxically, these patients are at an increased risk of bleeding due to great degree of platelet dysfunction and impaired interaction between platelet and endothelium. Currently, CHA2DS2-VASc and Hypertension, Abnormal liver/kidney function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HAS-BLED) are the recommended models for stroke risk stratification and bleeding risk assessment in patients with AF. There is conflicting data regarding benefits and risks of medications such as antiplatelet agents, warfarin and direct oral anticoagulants in ESRD patients with AF. Moreover, there is no randomized controlled trial data to guide the clinical decision making. Hence, a multi-disciplinary approach with annual re-evaluation of treatment goals and risk-benefit assessment has been recommended. In this article, we review the current recommendations with risks and benefits of anticoagulation in patients with ESRD with AF.

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Non‐Vitamin K Antagonist Oral Anticoagulants Provide Less Adverse Renal Outcomes Than Warfarin In Non‐Valvular Atrial Fibrillation: A Systematic Review and MetaAnalysis

Journal of the American Heart Association ◽

10.1161/jaha.120.019609 ◽

2021 ◽

Author(s):

Patita Sitticharoenchai ◽

Kullaya Takkavatakarn ◽

Smonporn Boonyaratavej ◽

Kearkiat Praditpornsilpa ◽

Somchai Eiam‐Ong ◽

...

Keyword(s):

Atrial Fibrillation ◽

Acute Kidney Injury ◽

Renal Disease ◽

End Stage Renal Disease ◽

Oral Anticoagulants ◽

Kidney Injury ◽

Incidence Rates ◽

Renal Outcomes ◽

Stage Renal Disease ◽

End Stage

Background Non‐vitamin K antagonist oral anticoagulants (NOACs) have better pharmacologic properties than warfarin and are recommended in preference to warfarin in most patients with non‐valvular atrial fibrillation. Besides lower bleeding complications, other advantages of NOACs over warfarin particularly renal outcomes remain inconclusive. Methods and Results Electronic searches were conducted through Medline, Scopus, Cochrane Library databases, and ClinicalTrial.gov. Randomized controlled trials and observational cohort studies reporting incidence rates and hazard ratio (HR) of renal outcomes (including acute kidney injury, worsening renal function, doubling serum creatinine, and end‐stage renal disease) were selected. The random‐effects model was used to calculate pooled incidence and HR with 95% CI. Eighteen studies were included. A total of 285 201 patients were enrolled, 118 863 patients with warfarin and 166 338 patients with NOACs. The NOACs group yielded lower incidence rates of all renal outcomes when compared with the warfarin group. Patients treated with NOACs showed significantly lower HR of risk of acute kidney injury (HR, 0.70, 95% CI, 0.64–0.76; P <0.001), worsening renal function (HR, 0.83; 95% CI, 0.73–0.95; P =0.006), doubling serum creatinine (HR, 0.58; 95% CI, 0.41–0.82; P =0.002), and end‐stage renal disease (HR, 0.82; 95% CI, 0.78–0.86; P <0.001). Conclusions In non‐valvular atrial fibrillation, patients treated with NOACs have a lower risk of both acute kidney injury and end‐stage renal disease when compared with warfarin.

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Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease

Journal of Cardiovascular Pharmacology and Therapeutics ◽

10.1177/1074248419858116 ◽

2019 ◽

Vol 24 (6) ◽

pp. 499-508

Author(s):

Junaid A. B. Zaman ◽

Anil K. Bhandari

Keyword(s):

Atrial Fibrillation ◽

Renal Disease ◽

End Stage Renal Disease ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Additional Risk ◽

Increased Risk ◽

Stage Renal Disease ◽

End Stage

The role of oral anticoagulants (OAC) in atrial fibrillation (AF) is well established. However, none of the randomized controlled trials included patients with end-stage renal disease (ESRD) leaving a lack of evidence in this large, challenging and unique patient group. Patients on hemodialysis (HD) with AF have additional risk factors for stroke due to vascular comorbidities, HD treatment, age, and diabetes. Conversely, they are also at increased risk of major bleeding due to uremic platelet impairment. Anticoagulants increase bleeding risk in patients with ESRD and HD up to 10-fold compared with non chronic kidney disease (CKD) patients on warfarin. There are conflicting data and recommendations regarding use of OACs in ESRD which will be reviewed in this article. We conclude by proposing a modified strategy for OAC use in ESRD based on the latest evidence.

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Stroke Prophylaxis in Patients with Atrial Fibrillation and End-Stage Renal Disease

Journal of Clinical Medicine ◽

10.3390/jcm9010123 ◽

2020 ◽

Vol 9 (1) ◽

pp. 123 ◽

Cited By ~ 1

Author(s):

Martin van Zyl ◽

Hafez M. Abdullah ◽

Peter A. Noseworthy ◽

Konstantinos C. Siontis

Keyword(s):

Atrial Fibrillation ◽

Renal Disease ◽

End Stage Renal Disease ◽

Oral Anticoagulants ◽

Current Evidence ◽

Care Utilization ◽

High Risk Population ◽

Unique Challenge ◽

Stage Renal Disease ◽

End Stage

Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention.

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Direct Oral Anticoagulants in End-Stage Renal Disease

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0037-1621715 ◽

2018 ◽

Vol 44 (04) ◽

pp. 353-363 ◽

Cited By ~ 5

Author(s):

Vicky Tagalakis ◽

Adi Klil-Drori

Keyword(s):

Atrial Fibrillation ◽

Venous Thromboembolism ◽

Renal Disease ◽

End Stage Renal Disease ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

The United States ◽

Current Evidence ◽

Stage Renal Disease ◽

End Stage

AbstractPatients with end-stage renal disease (ESRD) were excluded from pivotal clinical trials with oral anticoagulants. While such patients are at an increased risk of venous and arterial thromboembolism, their risk of bleeding is also elevated. It is thus of little surprise that stroke prevention with vitamin K antagonists (VKAs) in ESRD patients with atrial fibrillation is controversial, with observational evidence ranging from beneficial to harmful. This uncertainty extends to the less studied use of VKAs for venous thromboembolism in ESRD. The direct oral anticoagulants (DOACs) apixaban and rivaroxaban have now permissive labeling in the United States for atrial fibrillation in patients with ESRD; this expanded labeling has not yet occurred either in Europe or for venous thromboembolism. This review summarizes the current evidence for the pharmacology of DOACs in ESRD as well as their utilization and safety in patients with ESRD and atrial fibrillation.

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